|LETTER TO THE EDITOR
|Ahead of print publication
Perioperative anesthetic management of a pediatric patient for kasai procedure: a challenge to the anesthesiologist
Shalendra Singh, Shital A Dharamkhele, Debashish Paul, Venigalla Sri Krishna, Shibu Sasidharan
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||07-Jun-2020|
|Date of Decision||03-Aug-2020|
|Date of Acceptance||14-Aug-2020|
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Singh S, Dharamkhele SA, Paul D, Krishna VS, Sasidharan S. Perioperative anesthetic management of a pediatric patient for kasai procedure: a challenge to the anesthesiologist. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Mar 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=309951
Extrahepatic biliary atresia (EBA) is a lack of patency of the extrahepatic bile duct of infancy, which is fatal if untreated. It represents the most common surgically treatable cause of cholestasis encountered during the newborn period. If not surgically corrected, it invariably results in secondary biliary cirrhosis. The perioperative surgical concerns in such children are mentioned in the literature, but literature on perioperative anesthetic concerns is sorely lacking. Anesthesia for babies with biliary atresia poses significant challenges to the anesthesiologist as the degree of liver dysfunction leads to altered drug metabolism and coagulopathy. We share the anesthetic management of a 16-week-old infant with EBA requiring Kasai hepatoportoenterostomy (KHPE).
A 16-week-old female infant, a known case of EBA since birth, of American Society of Anesthesiologists physical Status III was posted for KHPE. She was malnourished, weighed 2.6 kg, and had growth retardation due to poor oral intake. Clinical examination revealed icterus and hepatosplenomegaly. Investigations showed hemoglobin 10.5 g/dL, total leukocyte count 14,500/mm, platelet count 3.5 lac/mm, serum sodium 138 mEq/L, serum potassium 4.8 mEq/L, random blood sugar 92 mg/dL, serum bilirubin 14.5 mg/dL, serum glutamic-oxaloacetic transaminase 158 IU/L (normal, 15–45), serum glutamic pyruvic transaminase 107 IU/L (normal, 15–45), alkaline phosphatase 785 IU/L (normal, 50–300), blood urea 22 mg/dL (15–45), serum creatinine 0.9 mg/dL (0.6–1.2), prothrombin time 12.5 s (test) and 14 s (control), and activated partial thromboplastin time for test 37.6 s and for control 30 s (normal, 20–40 s). In the operating room, routine monitors (electrocardiogram, pulse oximeter, and noninvasive blood pressure) were attached. On the day of surgery, injection fentanyl 08 micgm intravenously (IV) was given preinduction, and anesthesia was induced with injection propofol 5 mg IV. In addition, capnography and temperature monitoring was done. After induction of anesthesia, atracurium 2 mg was given to facilitate intubation with a 2.5 cm ID uncuffed tube using the Macintosh laryngoscope size 1 blade. Anesthesia was maintained with O2:N2O (40:60 ratios) and isoflurane 0.5%–1%, and fentanyl and atracurium IV were given in aliquots. The patient's temperature was maintained using warm fluids, Bair Hugger body warmer, and by adequately covering the exposed body parts with cotton. Hepatic roux-en-y portoenterostomy with Ladd's procedure was done. A volume of 350 ml of 1% dextrose in Ringer's lactate was infused over a period of 4 h. Blood loss of 150 ml was replaced with 120 ml of a packed red blood cell. Intraoperative blood glucose monitoring was done and euglycemia was maintained. Postoperative analgesia was provided with intravenous paracetamol. Postoperatively, an epidural catheter was placed through caudal space for postoperative pain relief and a 4 ml bolus of 0.125% bupivacaine was given. Following surgery, the neuromuscular blockade was antagonized and the patient extubated on the table when fully awake. She was shifted to the pediatric intensive care unit for hemodynamic monitoring and postoperative care.
Our patient, a 16-week-old infant, presented preoperatively malnourished, with grossly deranged liver function and portal hypertension. Nutritional deficiency and deranged liver function lead to hypoproteinemia, anemia, coagulopathy, and electrolyte imbalance that may affect the pharmacokinetics and pharmacodynamics of anesthetic agents. Shifts in the volumes of fluid compartments and alterations in the levels of albumin and other plasma proteins can affect volumes of distribution and unbound fractions unpredictably. Phase 1 reactions are also variably altered depending on the degree of impairment of hepatocellular function. The main anesthetic challenges are blood loss, intermittent interruption of venous drainage via the inferior vena cava by surgical retraction, and provision of adequate postoperative analgesia. Infection is also common because of decreased immunity in these patients. Blood has to be kept ready as coagulopathy maximizes blood loss. Airway pressures should be closely monitored as even minor endotracheal tube displacements can lead to inadvertent endobronchial intubation. The patient's hydration should be well maintained to prevent any inspissation of secretions in the airway and to minimize potential chances of airway compromise. Postoperative analgesia is a concern as a large subcostal incision is performed. The large incision may also lead to respiratory insufficiency. Avoidance of hepatotoxic drugs as far as possible is vital to prevent further liver damage. Paracetamol should be used judiciously as a part of multimodal analgesia as it is hepatotoxic. Unlike in adults, the use of diuretics or volume loading has no role in the prevention of renal failure because it virtually does not occur in this age group. In addition, due to intermittent compression or kinking of the inferior vena cava intraoperatively, it is advisable to use cardiac output monitoring.
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Conflicts of interest
There are no conflicts of interest.
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